Palpitations in General Practice

Dr Jess Fletcher
MBChB (Hons) MRCP MRCGP
 What are Palpitations?
• Palpitations are a symptom characterised by
awareness of the heartbeat, often described
as a strong, skipping, fluttering, racing,
pounding, thudding, or jumping sensation in
the chest.
• Some patients describe a sensation of having
to cough or their breath being taken away.

• However, patients occasionally mean

something other than palpitations (eg. chest
discomfort) which may need a different line of
investigation.
 Causes of palpitations
• List the common causes of palpitations you
see in general practice
• Can you group the causes?
 Evaluation and outcomes of patients with
palpitations
Weber BE Kapoor WN Am J Med 1997
• Prospective cohort study presenting with
palpitations
• 197 consecutive patients
• At Student medical centre
 Outcomes
• Cardiac (43%)
• Psychiatric (31%)
• Miscellaneous (10%)
• Unknown (16%)
etiology of papitations

cardiac
psychiatric
miscellaneous
unknown
 But please note….
• A large proportion of patients with
palpitations are diagnosed as having panic,
stress, or anxiety when, instead, they have an
underlying arrhythmia
 Unrecognised Paroxysmal
Supraventricular Tachycardia. Potential for
misdiagnosis as panic disorder
Lessmeier et al Arch Inter Med 1997

• Retrospective study
• 107 consecutive pts with re-entrant pSVT
• pSVT missed after initial medical evaluation in 55%
• Remained unrecognised for median of 3.3 yrs
• Ablation therapy 81% pts
• Symptom resolution 86%
• Post ablation, 4% met DSM-IV criteria of panic disorder
 Cardiac Causes
• List
 Cardiac Causes

SVT
AF/Aflutter

tacharrhymias

Cardiac cause of VT
palpitations (Related to exercise)
Extrasystoles
“skipped/missed beat”
Commonest cause
 Extrasystoles
• Generally not associated with significant
structural heart disease
• Common
• Frequent ventricular extrasystoles in >55 yr
old more concerning (>30 per hr) might
suggest underlying myocardial ischaemia
 Paroxysmal supraventricular
tachycardia

• Conduction abnormalities in atrio-ventricular

node or bypass tracts
 Atrial Fibrillation
Atrial Flutter
• 5 commonest underlying causes?
 Atrial Fibrillation
Atrial Flutter
• Hypertension
• IHD
• Valvular heart disease
• DM
• Hyperthyroidism
• Chronic alcohol misuse
• Obesity
 AF
• Classification, pathophysiology, and mechanisms of AF: key points
• Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia

• AF is usually classified as paroxysmal, persistent, or permanent.

• AF adversely affects cardiac haemodynamics because of loss of atrial
contraction and the rapidity and irregularity of the ventricular rate
• AF causes significant symptoms in approximately two thirds of patients
• AF is associated with a 1.5- to 2-fold increase in mortality
• AF is associated with a 6-fold increase in risk of stroke
• AF is initiated by rapid electrical activity, often arising from
arrhythmogenic foci located in the muscular sleeves of pulmonary veins.
• After a period of continuous AF, electrical remodelling occurs, further
facilitating AF maintenance
 Non cardiac causes
• Metabolic disorders (thyrotoxicosis,
hypoglycaemia, pheochromocytoma)
• Medication induced (vasodilators,
anticholinergic drugs)
• Central nervous system stimulants
(caffeine, cocaine, amphetamines)
• Psychiatric disease (panic attacks,
generalised anxiety disorder, depression)
 History
• 7 key questions
 History
1. What does the patient mean by palpitations?
2. Tap out rhythm on table
3. Duration/ Frequency
4. Severity ?have to sit down?collapse. If syncope urgent
referral
5. Associated chest pain or breathlessness (IHD associated
?fast AF)(“breath taken away” - extrasystoles
6. Exercise related? (urgent referral –
?cardiomyopthy/ischaemia/channelopathy)
7. How do they end? Can you stop them? (Valsalva/diving
reflex suggests SVT)
 History continued
• Drug History –thoughts?
What does this ECG show?
Drugs that prolong the QT interval
• Erythromycin
• Moxifloxacin
• Haloperidol
• Amiodarone
• Amphetamines
Drugs associated with
tachyarrhthymias
 Drugs that are associated with
tachyarrhythmias
• β agonists (salbutamol),
• antimuscarinics (amitriptyline),
• theophylline (phylocontin),
• dihydropyridine calcium channel blockers
(nifedipine),
• class 1 anti-arrhythmics (flecainide,
disopyramide),
 Drugs
• Caffeine (sinus tachycardia )
• Alcohol (AF)
• Illicit drugs
 History continued
• Fever or underlying infection (AF)
• History of Anaemia (sinus tachycardia)
• Family history sudden cardiac death <40 yrs
 Brugada Syndrome
• Video BHF
 Examination
• What do you look for?
 Raised JVP Ankle oedema

Signs of heart
failure

Gallop rhythm Bi-basal crackles

Tremor Goitre

Thyrotoxicosis
signs

Eye signs Thin

 Examination continued
• Listen for murmur
• Check for pallor
• Check BP for underlying hypertension
 Tests

FBC

U+E

TFT
 Case
• 40 yr old man
• Walk in -Asking for urgent GP appointment
• “Rapid fast palpitations and light headed”
• Told in past to see GP urgently if reoccurs for
assessment while symptomatic
• What do you do?
• History:
• 3 previous episodes
• Self limiting after 10-15mins
• No chest pain
• No other significant history
• Examination
• P160bpm regular
• BP 98/50
• No sign of heart failure
 SVT
• Vagal manouvres, diving reflex
• Sinus rhythm restored

• Copy of ECG to patient to keep

• For patients with infrequent palpitations,
asking them to attend your practice or the
emergency department to have an
electrocardiogram recorded during symptoms
is not unreasonable.
 ECG
• What are you looking for on ECG to give clues
as to underlying cause?
 12 lead electrocardiogram practice pointers for
palpitations—when to consider specialist referral
• Atrial fibrillation or atrial flutter
• Second degree atrioventricular block
• Third degree atrioventricular block
• Myocardial infarction
• Left ventricular hypertrophy (with or without strain
pattern)
• Left bundle branch block
• Abnormal T waves and ST segments
• Pre-excitation (Wolff-Parkinson-White pattern of a slow
rise in the initial portion of the QRS (delta wave))
• Abnormal QT/QTc interval
 If ECG normal
• Guidelines from the American College of
Cardiology
• Recommend Holter monitoring in patients
with palpitations and syncope , near syncope
(episodic dizziness or lightheadedness in
patients with known cardiac disease), and
recurrent palpitations if the resting ECG is
normal.
 Ambulatory Rhythm Monitors
• 24 hour Holter monitor to patients who have at
least daily symptoms,
• a 48 hour Holter monitor to those with symptoms
on most days,
• and a seven day monitor to those with weekly
symptoms, even if the 12 lead electrocardiogram
is normal.
• Inappropriate use of short periods of ambulatory
monitoring for infrequent symptoms is
cumbersome for patients, delays the diagnosis,
and is costly.
 Urgency of referral
• Low risk features for which referral is not mandatory
• Isolated palpitations (described as skipped beats,
pounding, or short fluttering) that are not provoked by
exercise and not associated with symptoms such as
lightheadedness, syncope, persistent breathlessness, or
chest pain;
• No history or signs of structural heart disease, heart
failure, or hypertension and no family history of
sudden cardiac death; and
• A normal 12 lead electrocardiogram.
• In these cases, palpitations are generally due to
extrasystoles or sinus tachycardia.
 Urgency of Referral
• Urgent cardiology referral
• Palpitations during exercise;
• Palpitations associated with syncope or pre-
syncope;
• Family history of sudden cardiac death or
inheritable cardiac conditions; or
• Second degree or third degree atrioventricular
block on the 12 lead electrocardiogram.
 Driving
• In the United Kingdom, the Driver and Vehicle
Licensing Agency (DVLA) regulations state that if
an arrhythmia has caused incapacity or is likely to
cause incapacity, the patient must not drive.
• It is the clinician’s responsibility to notify the
patient of this, document it in the case records,
and advise the patient to contact the DVLA, who
will make the final recommendation.
 Citations
• Assessment of palpitations
• BMJ 2016; 352 doi:
https://doi.org/10.1136/bmj.h5649 (Publishe
d 06 January 2016)Cite this
as: BMJ 2016;352:h5649
• Markides V, Schilling RJ
• Atrial fibrillation: classification,
pathophysiology, mechanisms and drug
treatment
• Heart 2003;89:939-943